Luther Memorial Church VBS 2023

Monday, July 10 – Thursday, July 13
6:00pm-8:30pm
Luther Memorial Church
1210 Jersey St, Quincy, IL 62301

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Email *
Child's Last Name *
Child's First Name *
Address *
City *
State *
Zip Code *
Child's Date of Birth *
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/
DD
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Child's Age *
Grade child will enter in 2023-2024 school year *
Does the child have any food allergies or other medical concerns? *
Are there any concerns we should be aware of?
Parent(s) or Guardian(s) Last Name *
Parent or Guardian's First Name *
Full address (Street #, Street name, City, State, ZIP) IF DIFFERENT FROM CHILD
Parent Home Number
Parent Cell Number *
Emergency Name and Phone if guardian cannot be reached *
Home Church  *
By participating in VBS, Luther Memorial has my permission to use photos with my child in them for any legal use, including but not limited to: publicity, advertising, and web content.  Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such. *
How did you hear about us (check all that apply) *
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A copy of your responses will be emailed to the address you provided.
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